David E. Biffar

Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements

IntroductionThe Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents.Materials and methodsAt our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course.ResultsThis report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum.ConclusionA multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.

A novel and inexpensive ballistic gel phantom for ultrasound training

BACKGROUND Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel. METHODS Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations. RESULTS The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy. CONCLUSIONS The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Construction of a reusable, high-fidelity model to enhance extracorporeal membrane oxygenation training through simulation.

Initiation of extracorporeal membrane oxygenation (ECMO) is stressful, especially for inexperienced extracorporeal life support providers. The main objective of this study was to create a novel, reusable mannequin for high-fidelity simulation of ECMO initiation. We modified a Laerdal neonatal mannequin (SimNewB; Stavanger, Norway) so that it could be used to simulate an ECMO initiation. A simulation of a neonatal patient suffering from meconium aspiration was performed in the pediatric intensive care unit, and participants included new extracorporeal life support specialists in addition to the composition of the clinical ECMO team. A total of 17 individuals participated in the neonatal ECMO initiation simulation. Questionnaire results showed that 88% of participants felt better prepared to assist in an ECMO initiation after the simulation. All participants (100%) agreed that the modified mannequin and the environment were realistic and that this simulation helps teamwork and communication in future initiations of ECMO. Simulation can be used for the prevention, identification, and reduction of anxiety–related crisis situations that novice providers may infrequently encounter during routine clinical use of mechanical circulatory support. Use of a reusable, high-fidelity mannequin may be beneficial for effective team training of complex pediatric ECMO–related procedures.

Simulation trainer for practicing emergent open thoracotomy procedures.

BACKGROUND An emergent open thoracotomy (OT) is a high-risk, low-frequency procedure uniquely suited for simulation training. We developed a cost-effective Cardiothoracic (CT) Surgery trainer and assessed its potential for improving technical and interprofessional skills during an emergent simulated OT. MATERIALS AND METHODS We modified a commercially available mannequin torso with artificial tissue models to create a custom CT Surgery trainer. The trainers feasibility for simulating emergent OT was tested using a multidisciplinary CT team in three consecutive in situ simulations. Five discretely observable milestones were identified as requisite steps in carrying out an emergent OT; namely (1) diagnosis and declaration of a code situation, (2) arrival of the code cart, (3) arrival of the thoracotomy tray, (4) initiation of the thoracotomy incision, and (5) defibrillation of a simulated heart. The time required for a team to achieve each discrete step was measured by an independent observer over the course of each OT simulation trial and compared. RESULTS Over the course of the three OT simulation trials conducted in the coronary care unit, there was an average reduction of 29.5% (P < 0.05) in the times required to achieve the five critical milestones. The time required to complete the whole OT procedure improved by 7 min and 31 s from the initial to the final trial-an overall improvement of 40%. CONCLUSIONS In our preliminary evaluation, the CT Surgery trainer appears to be useful for improving team performance during a simulated emergent bedside OT in the coronary care unit.

Telepresent Intubation Supervision Is as Effective as In-Person Supervision of Procedurally Naive Operators

BACKGROUND Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. MATERIALS AND METHODS A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. RESULTS There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. CONCLUSIONS In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

Feasibility of Air Transport Simulation Training: A Case Series.

Limited clinical site availability and an increased need for clinical training experiences often make it difficult for prehospital health care providers to complete new and annual training requirements. Medical simulation provides an alternative learning environment that provides trainees the opportunity to acquire and perfect new clinical skills without compromising patient care. The following is a detailed description of an air medical transport simulation of a neonate with hypoxic ischemic encephalopathy requiring transport to a higher level of care. Patient parameters were altered during flight to simulate potential complications unique to air medical transport. Use of this training strategy is particularly beneficial for low-volume, high-risk patients, and these lessons can be applied across all age patient groups, making the experience broadly applicable.

Evaluation of an Innovative Bleeding Cricothyrotomy Model

Objectives Emergency medicine (EM) residents are required to perform a cricothyrotomy during training as per the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Cricothyrotomy is a rare procedure, comprising 0.45% of emergency department airway management procedures. Procedural competence in utilizing a realistic trainer is of utmost importance. We have developed a cricothyrotomy trainer using a fused deposition modeling (FDM) three-dimensional (3D) printer and innovative bleeding tissue to enhance fidelity. We aim to evaluate the trainer’s realism. Methods Implementation occurred during a difficult airway educational lab for EM residents in April 2018. Participants completed anonymous written surveys after performing a cricothyrotomy on the trainer. The survey evaluated the realism of the trainer and compared it to other available models by utilizing five-point visual analog scales (VAS). The participants rated their comfort level in performing the procedure pre- and post-educational lab on a five-point VAS. Demographic data included postgraduate year, prior clinical cricothyrotomy experience as a primary operator versus as an assistant, and previous trainer experience. The survey included open-response suggestions for trainer improvement. Results Forty-three EM residents completed the survey (82.7%, 43/52). The mean realism rating of the trainer was 3.81 (95% CI = 3.54-4.1). The participants reported previous training on cadaver (62.8%, 27/43), porcine (46.5%, 20/43), and manikin (67.4%, 29/43) models prior to using this trainer. The bleeding cricothyrotomy trainer was rated higher than other models (4.45, 95% CI = 4.28-4.63). Participants noted improved comfort with performing the cricothyrotomy after the educational lab (average improvement of 1.23±0.75). Participants specifically commented on the realism of the bleeding and skin texture; however, they also recommended a reduction in the size of the cricothyroid membrane space. Conclusion The innovative bleeding cricothyrotomy trainer has greater fidelity and reported superiority when compared to other commonly used nonbleeding models. This trainer provides a more advanced platform to teach an infrequent yet critical procedural skill to emergency medicine residents.

Board 342 - Research Abstract Telepresent Intubation Instruction Is As Effective As In-Person When Instructing Naive Intubators (Submission #185)

Introduction/Background Tracheal intubation is a critical, life-saving skill for emergency care providers but many training facilities do not have access to experienced, high-quality instructors. Telepresence is emerging in clinical and educational settings as a potential modality to address this issue as it makes highly specialized experts unconstrained by geographical limitations. This study aimed to compare the effectiveness of a telepresent intubation instructor to the same instructor in-person teaching procedurally naïve medical students. Our hypothesis was that telepresent instruction is as effective as in-person instruction. Methods A randomized, crossover study was performed in a simulation lab with 48 first and second year medical students who had no intubation training or experience. An advanced airway trainer (Gaumard) was used with the tongue edema feature activated. Each participant received all four interventions [direct laryngoscopy (DL) with in-person instructor, DL with telepresent instructor, video laryngoscopy (VL) with in-person instructor and VL with telepresent instructor]. The order of interventions was randomly assigned. The same instructor was used for all participants and all trials to minimize variability in instruction. A C-MAC® video laryngoscope was used for all trials but for the DL trials the C-MAC® video screen was turned out of the participants’ sight. For remote instruction, an iPhone was mounted on the C-MAC® stand; for remote DL trials the camera was aimed at the side of the intubation manikin’s head so that the instructor could clearly see the students’ handling of the laryngoscope and endotracheal tube and for VL trials the camera was aimed at the C-MAC® video screen. For telepresent trials, the instructor was located in another room using an iPhone or iPad with FaceTime connection. The instructor was unscripted and the participants were able to ask questions. Data were collected by a research assistant who timed the intubation attempts and recorded the number of times the blade entered the mouth and times the tracheal tube tip passed the lips. The four study outcomes (and analysis used for each) were as follows: Time to intubation (median regression), first pass success (logistic regression) and number of additional blade and tube attempts after the first (negative binomial regression). We used multivariable regression to analyze the relationship between telepresent vs. in-person instruction, device used (DL vs. VL) and order of each intervention (1–4) to each of our study outcomes. Results There was no significant difference between in-person vs. telepresent instruction for any of our outcomes. Controlling for device used and order of interventions: Median difference (in-person vs. telepresent) for time to intubation was three minutes (95% CI: 14, 20); odds ratio for first attempt success was 0.7 (95% CI: 0.3, 1.3); and the rate ratio for extra number of blade attempts (i.e. attempts in addition to first) was 1.1 (95% CI: 0.7 to 1.7) and for extra number of tube attempts it was 1.4 (95% CI: 0.9, 2.2). Additionally, the number of previous interventions was significantly related to shorter intubation times, improved first pass success and fewer additional blade or tube attempts (p<0.01), with each training session improving the intubation performance during subsequent training sessions. In addition, VL was superior to DL for each of the outcome variables (p<0.01). Conclusion Telepresent instruction was as good as in-person instruction for teaching intubation in procedurally naïve medical students in a simulation lab. Our Results suggest that when in-person instructors are not available, the use of a telepresent instructor along with the use of VL and several repetitions is an effective training strategy. This method of instruction could have applications in rural, remote and limited resource areas. Future study may be aimed at the use of telepresence in assisting experienced intubators with difficult airways. Disclosures Karl Storz Endoscopy - America Karl Storz Endoscopy - America.

Board 234 - Program Innovations Abstract A Seven Year Collaboration Between Three Colleges to Learn Interprofessional Skills During a CPR Team Behavior Simulation (Submission #1037)

Introduction/Background Teamwork failures and breakdowns in communication are consistently associated with adverse events in patient care.1,2 According to statistics released by the Joint Commission in 2004, communication failures are the primary root cause in over 70% of sentinel events.3 Studies have shown that simulation can be used effectively to teach teamwork skills and that skills acquired through simulation can improve student performance in clinical environments.4–9 The purpose of this study was to evaluate the effectiveness of an interprofessional CPR team behavior simulation program in introducing professional entry students at the University of Arizona Health Sciences Center (AHSC) to vital elements of interprofessional collaborative practice.10 In particular, we wanted to assess the impact of this course on student perception of teamwork skills such as closed-loop communication, constructive intervention, knowledge sharing, re-evaluation and summarizing,and mutual respect in the context of a critical code scenario. Methods In the seventh year of the program, we enrolled 374 students from the Colleges of Medicine (n=114), Nursing (n=163) and Pharmacy (n=97) in a cardiopulmonary resuscitation (CPR) simulation course. Simulation exercises were conducted simultaneously over a four week period at the Arizona Simulation Technology and Education Center (ASTEC) and the Steele Innovation Learning Center (SILC) at the University of Arizona. Prior to the simulation exercise, students were provided with the American Heart Association CPR video, reading material and a CPR lecture detailing the critical elements of effective resuscitation team dynamics.11 The students were then assigned to interprofessional teams of five to eight students for a one hour CPR simulation in which the team worked to resuscitate a human patient simulator that had gone into cardiac arrest. The composition of each team was designed to maximize professional heterogeneity. Students were assigned one of the following roles irrespective of their professional training: team leader, chest compressor (2), ventilator, defibrillator, IV/medication administrator, and code recorder. Roles were rotated in repeated iterations of the CPR simulation; each student was given the opportunity to be the team leader. A short debriefing was conducted by trained facilitators after each simulation to reinforce the elements of team dynamics and to discuss ways to improve teamwork in subsequent simulations. Retrospective pre-post surveys were collected to assess the effectiveness of the training on the students’ understanding and perception of core competencies in interprofessional collaborative practice. Survey items were rated on a 5-point qualitative Likert scale. These Results are based on an 81% survey response rate (n=303). Student’s self ratings showed significant improvement in understanding the elements of effective team dynamics (Pre 2.59±1.03, Post 4.14±0.74; P<0.001) and the different roles and responsibilities of the various healthcare providers during CPR (Pre 2.55±1.00, Post 4.11±0.81; P<0.001). Self perceived understanding of behaviors necessary to be an effective team leader during crisis management increased significantly post-training (Pre 3.09±0.92, Post 4.36±0.64; P<0.001). Eighty-nine percent of students felt that the simulation helped them understand the degree to which clear communication leads to better patient outcomes. Pharmacy students rated their initial knowledge lower than medicine and nursing students in all survey questions. Results: Conclusion The interprofessional CPR team behavior simulation provided an effective platform to combine professional students from three colleges in the Healthcare Sciences to emphasize the importance of interdisciplinary collaboration and teamwork in crisis management situations. The simulation improved the student’s knowledge of vital team and communication skills and attitudes towards working in interprofessional teams. References 1. Leonard MW, Frankel AS. Role of effective teamwork and communication in delivering safe, high-quality care. Mt Sinai J Med 2011;78(6):820-6. 2. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85-90. 3. Joint Commission on Accreditation of Healthcare Organizations. National patient safety goals for 2005 and 2004, Available at: www.jcaho.org/accredited+organizations/patient+safety/npsg.htm. 4. Shrader S, Kern D, Zoller J, Blue A. Interprofessional teamwork skills as predictors of clinical outcomes in a simulated healthcare setting. J Allied Health 2013;42(1):e1-6. 5. Brock D, Abu-Rish E, Chiu CR, Hammer D, Wilson S, Vorvick L, Blondon K, Schaad D, Liner D, Zierler B. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf 2013;22(5):414-23. 6. Solomon P, Salfi J. Evaluation of an interprofessional education communication skills initiative. Educ Health 2011;24(2):616. 7. O’Donnell JM, Goode JS Jr, Henker R, Kelsey S, Bircher NG, Peele P, Bradle J, Close J, Engberg R, Sutton-Tyrrell K. Effect of a simulation educational intervention on knowledge, attitude, and patient transfer skills: from the simulation laboratory to the clinical setting. Simul Healthc 2011;6(2):84-93. 8. Robertson B, Kaplan B, Atallah H, Higgins M, Lewitt MJ, Ander DS. The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training. Simul Health 2010;5(6):332-7. 9. Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, Sallisbury ML, Simon R, Jay GD. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to existing didactic teamwork curriculum. Qual Saf Health Care 2004;13(6):417-21. 10. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel, 2011. Washington, D.C.: Interprofessional Education Collaborative. 11. Field JM, Gonzales L, Hazinski MF. Advanced Cardiovascular Life Support. Provider Manual. Part 3. Effective Resuscitation Team Dynamics. American Heart Association 2006: 11-17. Disclosures Karl Storz Endoscopy - America I provide medical director oversight to area9, a Danish education company. These duties do not overlap with this academic work. Karl Storz Endoscopy - America Karl Storz Endoscopy - America.

Board 533 - Technology Innovations Abstract Developing a Novel Drain Loop Skin Abscess Model for Training Intern ED Students (Submission #1439)

Introduction/Background Drainage of cutaneous abscesses is a common procedure performed in emergency departments (ED) to treat skin and soft tissue infections. The rate of infections with community-acquired methicilin-resistant Staphylococcus aureus has increased significantly over the past two decades and accounts for almost 3% of all ED visits according to a study conducted in 2005.1 Incision and drainage of cutaneous abscesses are essential procedural skills that need to be developed during the course of resident physician training. Simulation models can be used to improve technical skills outside of direct patient contact and studies have shown that skills acquired through simulation training transfer to the clinical setting.2-4 Several simulated abscess models have been developed but each has limitations of design and functional fidelity.5-7 The objective of this study was to develop a novel, easy-to-make loop drain abscess model and to evaluate it for use in ED resident training. Methods Using artificial tissue and simulated purulence, we developed an easy-to-make loop drain abscess model. The simulated purulence was prepared by mixing tapioca pudding with a trace amount of artificial blood. Platinum silicone was used to create two thin sheets of artificial skin, each measuring 12x12 inches. The sheet was compartmentalized to create 4 separate abscess models. For each abscess we developed three, one inch loculations by wrapping simulated purulence in saran wrap and glued them to the underlying tissue in the center of each compartment. Silicone glue was spread along the borders of the four compartments and a four-inch silicone tube (1/8-inch internal diameter) was placed to allow for injection of simulated purulence. The second artificial skin layer was placed on top of the bottom layer to create four chambers. The two layers of tissue were clamped together along the borders to ensure adhesion of the silicone glue. Once dry, 120cc of simulated purulence was injected into the chamber through the silicone tubing. The tubing was sealed with a large surgical clip and Graftobian skin tone powder was used to give the artificial skin a more realistic texture. We cut along the seal to separate the four abscess models. The use of the abscess model was subjectively evaluated by first- through third-year residents (n=22) and attending physicians (n=2) from the Department of Emergency Medicine in a one-hour abscess treatment and management simulation course. A ten-point Likert scale was used to assess nine specific aspects of its fidelity as a simulation model. These were categorized into three qualities: 1) Appearance of the skin: 1) pigmentation, 2) texture, and 3) elasticity.; 2) Qualities related to the incision: 1) tension of skin layer, 2) force required for incision, and 3) resistance to Kelly clamp.; 3) Qualities of the pus and loculations: 1) appearance and texture, 2) function, and 3) usability of the loop drain. Results: Conclusion All 9 aspects of the loop drain abscess model were rated as highly realistic with the lowest mean score given to the texture (6.92 ± 1.61) and the tension of the skin layer over the abscess (6.83 ± 1.71). Nonetheless, the users rated the model highly on usability of the loop drain (9.42 ± 1.02) and appearance and texture of the pus (9.0 ± 1.14). Noteworthy comments for future improvement of the model included making the loculations more fibrous and less solid. Users requested a more “spider web-like feel” when probing the abscess. We developed and tested a novel, easy-to-make drain loop abscess model that can be used in a simulation training of inexperienced Emergency Medicine physicians to practice incision and drainage of cutaneous abscesses. References 1. Pallin DJ, Egan DL, Pelletier AJ, Hooper DC, Camargo CA Jr: Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2008; 51(3):291-8. 2. Beyer L, Troyer JD, Mancini J, Bladou F, Berdah F, Berdah SV, Kersenty G: Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study. Am J Surg 2011; 202(3):265-72. 3. Barsuk JH, McGaghie WC, Cohen ER, O’Leary KJ, Wayne DB: Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med 2009; 37(10):2697-701. 4. Domuracki KJ, Moule CJ, Owen H, Kostandoff G, Plummer JL: Learning on a simulator does transfer to clinical practice. Resuscitation 2009; 80(3):346-9. 5. Cole FL, Ramirez E, Mickanin J: Skill station models for teaching incision and drainage of abscesses, felons, and paronychia to emergency nurse practitioners. J Emerg Nurs 1998; 24(5):455-6. 6. Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M: A skin abscess model for teaching incision and drainage procedures. BMC Med Educ 2008; 8:38. 7. Heiner JD: A new simulation model for skin abscess identification and management. Simul Healthc 2010; 5(4):238-41. Disclosures Karl Storz Endoscopy - America Karl Storz Endoscopy - America.